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General NPI Number Information
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NPI Number | 1588879134
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Entity Type | Organization
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Legal Business Name | MILLS PENINSULA MEDICAL GROUP
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Dates
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Enumeration Date | 05/14/2007
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Last Update Date | 01/31/2008
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Provider Practice Location Address
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Address Line | 50 S SAN MATEO DR SUITE 150
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City | SAN MATEO
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State | CA
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Zip | 94401-3857
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Country | US
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Telephone | 650-696-9770
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Fax | 650-375-1363
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Provider Business Mailing Address
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Address Line | 50 S SAN MATEO DR SUITE 150
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City | SAN MATEO
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State | CA
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Zip | 94401-3857
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Country | US
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Telephone | 650-696-9770
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Fax | 650-375-1363
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Authorized Official
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Title or Position | CLINIC DIRECTOR
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Name | TRUDY BRADY
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Credential | LVN
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Telephone | 650-240-8011
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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